Table 4.
Other guidelines regarding basal and premix insulin for type 2 diabetes mellitus.
| Recommendations* |
NICE 2008-2020
[ 46 - 50 ] |
RACGP 2011-2012 [ 51 ], 2014 [ 52 ], 2016-2018 [ 53 ], 2020 [ 54 ] | Diabetes Canada (Clinical Practice Guidelines) 2018 [ 55 ] | Diabetes Canada (Clinical Practice Guidelines) 2020 [ 56 ] |
IDF 2011-2017
[ 57 - 60 ] |
SEMDSA 2009-2017 [ 61 - 63 ] |
|---|---|---|---|---|---|---|
| Timing of insulin initiation | Nothing specific; however, insulin is recommended following inability to control blood glucose with OADs (mono- or combination) | International and Australian guidelines suggest considering a GLP-1 RA before commencing insulin, unless a person has extreme hyperglycemic symptoms or an HbA1c of >11%. Insulin should be initiated in patients with type 2 diabetes mellitus who are taking maximal doses of non-insulin glucose-lowering medicines and who have suboptimal glycemic control (HbA1c or blood glucose above individualized target), whether they are asymptomatic or symptomatic | If glycemic targets are not achieved with existing antihyperglycemic medication(s), other classes of agents should be added to improve glycemic control. [Grade B] Insulin should be immediately initiated in people with evidence of metabolic decompensation (such as marked hyperglycemia, ketosis, or unintentional weight loss) and/or symptomatic hyperglycemia, regardless of HbA1c level |
In people not achieving glycemic targets on existing noninsulin antihyperglycemic medication(s) [Grade B]. | Third-line therapy When glucose control targets are no longer being achieved, start insulin, or add a third oral agent. If starting insulin, add basal insulin or use premix insulin |
Consider insulin as first-line therapy at diagnosis, and at any other point in the course of the disease, in the setting of metabolic decompensation with any of the following features: • Catabolism (marked weight loss) • Fasting plasma glucose levels >14 mmol/l • Random glucose levels consistently >16.5 mmol/L • HbA1c >10% • Presence of persistent ketogenesis, ketoacidosis, or hyperosmolar nonketotic state [Grade C] |
| Number of OADs to be used before initiating insulin | Not specified | Three | Not specified. The use of OADs varies with the risk of comorbidities such as CVD | Not specified. The use of OADs varies with the risk of comorbidities such as CVD. | Insulin is recommended as third-line therapy | Consider adding basal insulin as the third glucose-lowering drug in patients not achieving or maintaining their glycemic targets on a two-drug oral regimen, especially if targets are unlikely to be achieved with other third-line options, and there are adequate resources to support insulin initiation and titration |
| Choice of initial insulin | Basal insulin alone has a slightly lower risk of hypoglycemia, especially if the fasting glucose is consistently above target | Basal insulin is to be preferred if fasting glucose is consistently above target levels. Premixed or coformulated insulin may be more appropriate and simpler for a patient where fasting and postprandial glucose are both consistently elevated |
In people not achieving glycemic targets on existing noninsulin antihyperglycemic medication (s), the addition of a once-daily basal insulin regimen should be considered over premixed insulin or bolus only regimens, if lower risk of hypoglycemia and/or weight gain are priorities [Grade B] |
The addition of a basal insulin regimen should be considered over premixed insulin or bolus-only regimens, if lower risk of hypoglycemia and/or preventing weight gain are priorities [Grade B] | Basal insulin should be preferred, and it can be temporary | If insulin is needed at diagnosis, use either premixed insulin twice daily or basal-bolus intensive insulin therapy (specialist referral is recommended) |
| Dose of insulin at initiation | Start with 10 unit or 0.2 units/kg | 10 units or 0.1-0.2 units/kg for premixed, coformulated, or basal insulin | Not specified. Number and timing of insulin injections may vary with the clinical situation | Not specified. Number and timing of insulin injections may vary with the clinical situation | Initiate insulin using a self-titration regimen | Initiate 10 units of basal insulin (or 0.2 U/kg) using intermediate or long-acting insulin (use insulins with a low acquisition cost; clones and biosimilar insulins are acceptable) |
| Dose titration | Titrate once or twice weekly at 1 to 2 units each time to achieve a target fasting blood glucose between 3.9 and 7.2 mmol/L (70 and 130 mg/dL) | Basal insulin: Adjust the dose based on previous average fasting glucose levels. Increase by 2 U/kg every 3 days until the FPG target is achieved. Premix insulin: Adjust evening dose once/twice a week based on FPB levels |
Not specified. Number and timing of insulin injections may vary with the clinical situation | Not specified. Number and timing of insulin injections may vary with the clinical situation | Increase by two units every 3 days or biweekly or more frequently (as suggested by a healthcare professional) | Simple titration: Once weekly average of the last two fasting SMBG levels (use preprandial SMBG for premix or bolus insulin). Simple rapid titration: Once-daily titration according to the last fasting SMBG level (use preprandial SMBG for premix or bolus insulin). Aggressive titration: Once weekly lowest of the last 3 fasting SMBG readings (use preprandial SMBG for premix or bolus insulin) |
| Dose intensification | Not specified | Basal plus, basal-bolus, or switch to premix insulin. Premix insulin: Intensify to twice daily. |
GLP-1 receptor agonist should, be considered before bolus insulin as add-on therapy in people on basal insulin (with or without other agents) who require antihyperglycemic treatment intensification if there are no barriers to affordability or access |
Add GLP1-RA, SGLT2i, or DPP4i if target levels are not achieved. [Grade B] Progress to the addition of bolus insulin or multiple injections with bolus injection at each meal | - | - |
Note: **Grade of evidence has been specified in italics wherever available.
Abbreviations: CVD: Cardiovascular disease; DPP4i: Dipeptidyl peptidase-4 inhibitor; FPG: Fasting plasma glucose; GLP1-RA: Glucagon-like peptide-1 receptor agonists; IDF: International Diabetes Federation; NICE: National Institute for Health and Care Excellence; OAD: Oral antidiabetic drug; RACGP: Royal Australian College of General Practitioners; SEMDSA: Society for Endocrinology, Metabolism, and Diabetes of South Africa; SMBG: Self-monitored blood glucose; SGLT2i: Sodium/glucose cotransporter-2 inhibitor.